Post-operative complications Flashcards
Potential complications
- Respiratory failure->heart and lungs
- Wound failure->check wound site
- Confusion->orientation
- Pyrexia->vitals
- Deep vein thrombosis->painful calves, mobilising, DVT prophylaxis
- Oliguria->urine output
- Hyponatremia->bloods
- Hypernatremia
- Hypo/hyperkalemia
- Hemorrhage
- Vomiting
Causes of respiratory failure
- Pulmonary embolism
- Acute lung injury/ARDS
- Abdominal distension
- Opiate overdose
Potential wound failures
1. Discharge of fluid (serous, blood, serosanguinous, infected fluid) 2. Collection of fluid (blood, pus, seroma--> large incision in SC or lymphatic damage-->lift skin off tissues and impede wound healing 3. Disruption of the wound
Risk factors for wound breakdown
1. General DM Immunosuppression Malignancy Malnutrition 2. Local Wound closure Infection Foreign body Mechanical stress
Serous versus serosnguinous from wound
- serous may be little significance
- Serosanguinous–> 5-8 days post may be due to dehiscience
with evisceration. Sterile dressing
consider taking back to surgery
Causes of post-operative confusion
- Hypoxia->pneumonia, PE, cariac
- Sepsis
- Drug withdrawal, drug effects
- Metabolic/electrolyte
- Urinary retention
Management of confusion
- Study charts
- Co-morbidities
- Drug/alcohol
- History and examine
- Consider oxygen
Consider ABG, FBC/UEC/LFTs,
blood/urine culture, CXR, echo? - May need sedation->midazolam, haloperidol
Define normal temperature
A normal temperature is 36.5-37.5
What considerations with post-op pyrexia
- Type of fever
- Procedure
- Temporal relationship
Fever within 24 hours
- ATELECTASIS
2. Metabolic response
Fever days 5-7
Usually infection
Pulmonary can
Consider: infection of the wound, operative site or urinary tract
Cannula and DVT!
Fever >7 days post op
Abscess
Also remember–> drugs, transfusion, brainstem as cause of
+temperature
Causes of oliguria
Diminished output
most commonly hypovolemia
2. Intra-renal (ATN)
3. Post renal failure: Need accurate matching input and output
Most ensure not in acute urinary retention
Common causes of oliguria in terms of procedure and ileus
- Underestimating fluid loss in procedure
2. Ileus->fluid becomes sequestered in the gut
Cause of hyponatremia and management
- Mostly dilutional
- +ADH
Fluid restriction 2L until diuresis settles
Causes of hypernatremia and management
Usually secondary to reduced water intake 1. Administer water by mouth or IV dextrose 2. Max reduction 10mmol/L in 24 hours redution/L dextrose= sodium concentration/ (TBW +1)
Types of hemorrhage related to surgery
Localised 1. Primary- within procedure 2. Reactionary- w/i 24 hours of procedure, most commonly from poorly ligated blood vessel 3. Secondary 7-10 days after operation-->most often erosion of vessel from spreading infetion, intraperitoneal bleeding, GIT hemorrhage, disordered hemostasis
Causes of vomiting
- Drugs->immediate
- Gut atony->self limiting
- If >7 days->consider mechanical course
Causes of post-op fever and timeframe
1. Wind Pulmonary 1-3 days Atelectasis, pneumonia Exacerbate pre-existing 2. Water UTI day 3-5 3. Wound Infection day 5-8 4. Walk Venous->DVT, PE, Thrombophlebitis 5. Wonder drugs Any drug can cause
Timing of post-op fever to identify cause
1. Hours after POD 1 Inflammatory Blood reaction Malignant hyperthermia 2. POD 1-2 !Atelectasis Early wound Aspiration pneumonitis Addisonian, thyroid storm Transfusion reaction 3. POD 3-7 UTI Surgical site infection Septic thrombophlebitis Leaked anastamosis 4. POD 8 Intra-abdo abscess DVT/PE, drug fever Cholecystitis, peri-rectal abscess, URTI, seroma/hematoma/biloma that's infected C dif colitis, Endocarditis
Immediate post-operative management
- Pain and other medications
a. analgesia,
b. antibiotics
(prophylactic or therapeutic),
c. sedatives,
d. antiemetics and
e. anticoagulants/DVT prophylaxis–>
ensure charted and being
administered where relevant - Monitoring
vitals, (may include cVP),
Fluid input and output
Normal fluids noted
If fluid shifts/renal reduce–>
catheter and review hourly
Check UEC, CRP, eGFR, haem regularly - Mobilisation
as early/much as can (not in
epidural catheter,
multiple injuries)
Physio–> help flow, reduce
DVT risks - Communication
- Respiratory
- Fluid balance
- Gut function
- Drain and catheter care
Respiratory considerations
- Control of pain
- Regular hyperinflation with inhalation spirometry
- Early mobilisation
Gut function considerations
1. Gastric dilitation: 2-3 days post-->massive fluid secretion, risk of regurg and aspiration Insert NGT and decompress 2. Paralytic ileus: first post op following peritonitis or 5 days post. Abdominal distention and vomiting a. Oral fluid restriction b. IV replacement c. Most resolve spontaneousl d. May consider pro-kinetic agents 3. Pseudo-obstruction: elderly who has surgery for fractures NOF a. If not resolving spontaneously, colonoscopic decompression
Principles of fluid balance
- Correct abnormalities
- Provide the daily requirements
- Replace any abnormal/ongoing losses
Daily requirements
basic requirements 45-60% TBW 2/3 intracellular 1/3 plasma water (25% of extracellular fluid) and interstitial fluid (75% of extracellular fluid). Na and potassium daily requirements: 100–150 mmol and 60–90 mmol-->will balance loss in urine Daily requirement for maintenence 2-3L: Loss: 1500 mL in the urine and about 500 mL from the skin, lungs and stool
What do you need to do prior to potassium supplementation
Need to ensure kidneys are functioning
Approximting losses from gastric, duodenal, diarrhea, upper GI, lower
Gastric--> +chloride, sodium, small potassium Duodenal/biliary/ pancreat/jejuno/feces--> mostly Na, Cl and bicarb Diarrhea--> Na, Cl, potassium and bicarb Upper GI-->acid lost (metabolic alkalosis) Lower-->sodium and bicarb
Management of wound dishiscience and evisceration of the ward after laparotomy
- Assume defect involvles whole of the wound
- Put guts in abdomen, sterile dressing
- IV cannula, IV antibiotics, IVF
- Get senior help
- Let theatre know
- Analgesia
